Depo- Provera and HIV

Depo-Provera contraceptive increases risk of HIV infection: new study

March 8, 2016 (POP) -- A new peer-reviewed study,1
conducted in collaboration with the Population Research Institute
(PRI), shows that women who use Depo-Provera are significantly more
likely to acquire HIV.
Due to funding from organizations like the Bill and Melinda Gates
Foundation and agencies like the United Nations Population Fund (UNFPA),
Depo-Provera is the most widely used form of birth control by women in
Sub-Saharan Africa where HIV prevalence remains high.
The study found that
Depo-Provera and other DMPA based injectable contraceptives increased
women’s risk of acquiring HIV-1 by 49% compared to those not using
hormonal contraception.
Depo-Provera, a pharmaceutical brand owned by Pfizer, Inc., is a
long-term injectable contraceptive that prevents pregnancy for three
months.

The active ingredient in Depo-Provera, and other injectable
contraceptives like Depo Sub-Q Provera 104, is a progestin known as
depot-medroxyprogesterone acetate (DMPA). DMPA based injectable
contraceptives account for an estimated 70% of injectable contraceptives
procured by non-governmental organizations (NGOs) and government
agencies, like the UNFPA and the U.S. Agency for International
Development (USAID).

The study involved a meta-analysis of 23 articles from peer-reviewed
journals, making this study the largest of its kind to date. The authors
found consistent evidence that women using DMPA acquired the HIV-1
virus at significantly higher rates than the general population. In
total, 88% of cross-sectional studies and 75% of longitudinal studies
demonstrated a higher risk among DMPA users.
Joel Brind, Professor of Biology and Endocrinology at the City
University of New York, Steven Condly, Research Psychologist at the U.S.
Military Academy, Steven W. Mosher, President of the Population
Research Institute, Anne Morse, graduate student at Pennsylvania State
University, and Jennifer Kimball, Adjunct Professor of Bioethics at the
Ave Maria School of Law participated in the study.

The authors also delved into possible biological explanations for why
DMPA increases the risk of HIV. Researchers found a number of studies
showing that DMPA weakens the body’s immune system and thins natural
epithelial barriers that prevent the HIV virus from infecting women.
While study after study has demonstrated a clear and strong
association between HIV and DMPA, the World Health Organization (WHO),
the Gates Foundation and other interested parties involved in procuring
injectable contraceptives worldwide have been less keen on the issue.
The WHO’s failure to acknowledge the associated risk has caused a controversy that has spanned political persuasions on both the left and the right.
A controversial statement released
by the WHO acknowledges the evidence of an increased HIV risk. Yet, in
spite of the associated risks involved, the WHO recommends that:

There are no restrictions on the use of hormonal contraceptives, including DMPA for women at high risk of HIV (MEC Category 1)

While scientists are still not certain why women who used DMPA were
more likely to acquire HIV, a number of studies have found significant
evidence of possible causal associations between DMPA and HIV
transmission.
Huijbreghts, et al. (2013),2 for example, found
in in vitro experiments that MPA decreased immune cell’s production of
cytokines and chemokines essentially to the immune system and reduced
the proliferation of T-cells. Others like Govender, et al. (2014),3 have
shown that MPA, unlike endogenous progesterone, represses inflammatory
cytokines by acting as a glucocorticoid receptor agonist.
In spite of the evidence, the WHO claims:

There is no evidence of a causal association between DMPA use and an increase in women’s risk of HIV acquisition.

It is unclear why the WHO continues to ignore the evidence of the
associated risk of HIV. Some have suggested that the WHO and the U.N.
are catering to some their largest donors. Up to 10% of the WHO’s annual budget is
financed by the Bill and Melinda Gates Foundation. DMPA injectables are
often appealing for population control programs because they are not
subject to “user-error” and remain effective for long periods of time.

The WHO could also be turning a blind eye to the issue in light of
the recent release of Sayana Press, Pfizer’s one-time use DMPA
injectable intended for self-injection, which has been strongly promoted
with the support of the Gates Foundation, USAID, and others. Trial
introductions of the injectable in Africa have not relied on doctors and
nurses but rather largely on unlicensed community health workers for
distribution. A stronger statement from the WHO on recommendations for
DMPA use would necessarily hamper efforts to widely distribute the new
injectable contraceptive.
Depo-Provera is also one of Pfizer’s fastest growing products by
total sales, with an almost 30% increase in revenue from FY 2012-2013.
In 2014, Pfizer took in over $200 million in revenues from Depo-Provera
sales

Source: LifeSite News With HIV prevalence rates exceeding 20% of the adult population in some African countries, the WHO offers condoms as a solution to any possible risk associated with the use of DMPA. According to the WHO:

Women and couples at high risk of HIV acquisition considering
progestogen-only injectables should also be informed about and have
access to HIV preventive measures, including male and female condoms.

As Brind, et al. (2015) includes both DMPA users who
reported using and not using condoms, there is reason to doubt that the
recommendation—that serodiscordant and high risk couples use barrier
methods such as condoms for protection against HIV-1 transmission—will
be effective. As condom failure rates for pregnancy prevention are
18-21% within the first year with typical use,4 failure rates for STI prevention are likely similar.
Areas where HIV prevalence is high are also areas where condom use is inconsistent and has high failure rates.
A large study in Uganda5 showed inconsistent condom use
failed to protect against HIV acquisition. Inconsistent users were found
to contract HIV at incidence rates higher than persons who reported not
using condoms at all. Even as consistent usage was found to reduce the
risk, almost four times as many persons who reported using condoms used
them inconsistently rather than consistently. As Uganda ranked 10th in
the world for HIV prevalence among adults of reproductive age in 2013,
according WHO data, adopting a policy of recommending condom usage with
DMPA could have disastrous consequences.
Conversely, Niger, a country with one of the lowest contraceptive
prevalence rates in the world, has one of the lowest HIV prevalence
rates in Sub-Saharan Africa. Prevalence of HIV among adults of
reproductive age in Niger match those in Spain and are only 0.1% higher
than HIV prevalence in the U.K. According to 2012 data from the U.N.
Population Division, female contraceptive prevalence in the U.K. was
second only to China.
It is not likely that advising women who use DMPA to also use condoms
will have much effect. Even in the United States where contraceptive
prevalence and education remains high, among couples who report using
dual methods of contraception, over 40% reported using condoms
incorrectly and half fail to use them on a consistent basis.6 As less than one-third of South African women using hormonal contraception reported using dual methods,7 it is irresponsible to counsel women to use condoms as an effective means of protection against HIV.For more information about PRI’s new study and the promotion of injectable contraceptive worldwide, visit https://www.pop.org/depo-provera-hiv.
1. Joel Brind, Steven J. Condly, Steven W. Mosher, Anne R. Morse, and
Jennifer Kimball, “Risk of HIV infection in depot-medroxyprogesterone
acetate (DMPA) users: a systematic review and meta-analysis,” Issues in
Law & Medicine, 2015; 30(2):129-139.
2. Huijbregts, Richard P. H., E. Scott Helton, Katherine G. Michel,
Steffanie Sabbaj, Holly E. Richter, Paul A. Goepfert, Zdenek Hell,
“Hormonal contraception and HIV-1 infection: medroxyprogesterone acetate
suppresses innate and adaptive immune mechanisms,” Endocrinology, 2013;
154(3): 1282-1295, doi: 10.1210/en.2012-1850.
3. Govender, Yashini, Chanel Avenant, Nicolette J. D. Verhoog, Roslyn
M. Ray, Nicholas J. Grantham, Donita Africander, Janet P. Hapgood, “The
injectable-only contraceptive medroxyprogesterone acetate, unlike
norethisterone acetate and progesterone, regulates inflammatory genes in
endocervical cells via the glucocorticoid receptor,” PLOS ONE, 2014;
9(5), doi:10. 1371/journal.pone.0096497.
4. Lisa B. Haddad, Chelsea B. Polis, Anandi N. Sheth, Jennifer Brown,
Athena P. Kourtis, Caroline King, Rana Chakraborty, Igho Ofotokun,
“Contraceptive methods and risk of HIV acquisition or female-to-male
transmission,” HHS public access author manuscript, published in:
Current HIV/AIDS Reports, 2014; 11(4): 447–458,
doi:10.1007/s11904-014-0236-6.
5. Saifuddin Ahmed, Tom Lutalo, Maria Wawer, David Serwadda, Nelson
K. Sewankambo, Fred Nalugoda, Fred Makumbi, Fred Wabwire-Mangen, Noah
Kiwanuka, Godfrey Kigozi, Mohamed Kiddugavu and Ron Gray, “HIV incidence
and sexually transmitted disease prevalence associated with condom use:
a population study in Rakai, Uganda,” AIDS, 2001; 15:2171-2179.
6. Jenny A. Higgins, Nicole K. Smith, Stephanie A. Sanders, Vanessa
Schick, Debby Herbenick, Michael Reece, Brian Dodge, J. Dennis
Fortenberry, “Dual method use at last sexual encounter: a nationally
representative, episode-level analysis of US men and women,” HHS public
access author manuscript, published in: Contraception, 2014; 90(4):
399–406, doi:10.1016/j.contraception.2014.06.003.
7. Catherine MacPhail, Audrey Pettifor, Sophie Pascoe, Helen Rees,
“Predictors of dual method use for pregnancy and HIV prevention among
adolescent South African women,” Contraception, 2007; 75(5): 383-389.Reprinted with permission from Population Research Institute.